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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> 5i �C Fam l-lf f elio(eotC-9- S(200<S2O1 --Z- <br /> OWNER <br /> OWNER/OPERATOR f_ CHECK if BILLING ADDRESS❑ <br /> FACILITY NAME <br /> SIT AD RESS C T1 �-CA 85366 <br /> v 5— Street Number I Dire%tion 1 1 Street Name cityZi Code <br /> HOME or MAILING ADDRESS (If Different from Site Address) <br /> 0 / <br /> , n'JrI3 Street Number Street Name <br /> CITY2;19,OsA STATE ZIP �!� <br /> � I/ b <br /> PHONE#1 ExT• APN# LAND USE APPLICATION# <br /> (Z(4) 196 -70-9'9 CtAa� 2.03 -(,00-170 <br /> PHONE#2 ExT• BOS DISTRICT LOCATION CODE <br /> (20q) q'6g 638 -ev,,Z4r 9 � <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR I /I <br /> CHECK If BILLING ADDRESS❑ <br /> BUSINESS NAME v\ "l PHONE# ExT. <br /> 20 16 8 3 St-/ <br /> HOME or MAILING ADDRESS I �j I FAX# <br /> CITY /� STATE /� ZIP 153 <br /> BILLING``-ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL,HEALTH DEPARTMENT hourly charges associated with this project <br /> or activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, STATE and F DEKA ws. / <br /> APPLICANT'S SIGNATURE: DATE: A 3 <br /> PROPER /BUSINESS OWNER OPERATOR/MANAGER ❑ 'OVTHER AUTHORIZED AGENT❑ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment <br /> information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is avail.6 <br /> and at the same time it is <br /> provided to me or my representative. A ycc <br /> TYPE OF SERVICE REQUESTED: C� <br /> COMMENTS: <br /> SAN jo R 2 y ?020 <br /> ENVI AQU/N C <br /> t yO�gRrM COU <br /> WNT <br /> ACCEPTED BY: �J EMPLOYEE M DATE: y Z[I zj( jo <br /> ASSIGNED TO: JAEMPLOYEE#: DATE: q/,,7 Y1202-0 <br /> Date Service Completed (if already completed): SERVICE CODE: �3 PIE: �;U <br /> Fee Amount: j' Amount Pal �bg,00 1 <br /> Payment Date <br /> Payment Type �/ Invoice# Check# �7 Received By: <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />